MS Insights

Not All MS Cases Are Alike

There are different classifications of the disease, and one can evolve into another.

By Dr. Sanjay Gupta

Multiple
sclerosis is a disease of the nervous system that affects roughly 400,000
Americans. The myelin sheath, which protects the body’s nerve cells like
coating on a wire, becomes damaged and communication between the brain and
spinal cord is disrupted.

“In
MS, the immune system gets confused and attacks the brain and spinal cord,”
according to Robert Fox, MD, a staff neurologist at the Mellen Center for
Multiple Sclerosis at Cleveland Clinic. The effects of that “attack” vary
greatly – they can be so mild as to go unnoticed, flare up suddenly, or worsen
rapidly. “Some patients will have no problems at all; others may be wheelchair-bound,”
said Dr. Fox during our recent Everyday
Health Twitter chat
about MS.

Gary
Birnbaum, MD, director of the Multiple Sclerosis Treatment and Research Center
at the Minneapolis Clinic of Neurology, believes MS is more like a syndrome rather
than a single illness. Dr. Birnbaum points to “the multitude of disparate genes
involved … [and] the differences in responses to treatments.”

Based
on a survey of physicians, the National Multiple Sclerosis Society introduced in
1996 a classification system to describe four subtypes of MS. “The different
classifications of MS are based solely on clinical criteria,” said Birnbaum. “There
are no biological or MRI [magnetic resonance imaging] markers that permit
disease classification.”

Roughly
85 percent of MS patients are initially diagnosed with relapsing-remitting MS. These patients experience periods of active
symptoms followed by symptom-free remissions “that can last days...to years,”
according to Lily Jung Henson, MD, MMM, FAAN, of the Swedish Neuroscience
Institute and vice president of medical affairs at Swedish Ballard in Seattle.

As
Birnbaum points out, “any function of the central nervous system can be
affected, from vision to speech to balance to sensation to strength to
coordination.”

Primary-progressive
MS,
which is diagnosed in roughly 1 out of 10 MS patients, is a more serious form
of the disease in which attacks are rare but symptoms gradually worsen over
time.

Similarly,
people with progressive-relapsing MS
– the least common type of the disease – develop worsening symptoms but also
experience attacks and remissions. Unlike relapsing-remitting MS, people with the
progressive-relapsing form of the disease typically don’t fully recover after a
relapse.

Birnbaum
stresses, however, “none of these disease classifications are ‘clean,’ meaning
there may be considerable overlap between them.”

There
are also less common types of MS such as fulminant
MS, which the National Institutes of Health describes as “the most
malignant form” of the disease. “Fulminant MS is when the condition behaves
very aggressively, to the point where the patient may initially be thought to
have a tumor,” said Jung Henson.

In
people with fulminant MS, “there is inexorable progression of disease, with
little if any recovery from each episode, eventually resulting, within a short
period of time, in increasing disability, most often affecting motor and
respiratory function,” said Birnbaum. Fortunately, fulminant MS is very rare.

The
term “benign MS,” used to refer to
cases in which years or even decades pass between attacks, is not without
controversy. “The diagnosis can only be safely made retrospectively, and the
longer one follows individuals with so-called benign MS, the less likely they
are to retain this diagnosis,” said Birnbaum.

Regardless
of the type of MS, treatment has to be a team effort between patient and
doctor, according to Birnbaum. “I see my role as an informed provider of
diagnostic and treatment options, with predilections for particular
approaches,” he said. “However, the final decisions, be they diagnostic
procedures or treatment options, need to be made by patients, in conjunction
with their significant others, after evaluating all positives and negatives.”

“Symptoms
can fluctuate from day to day,” said Jung Henson. “So we rely on our patients
to track their symptoms and let us know how they are doing.”

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